Does A4453 require prior authorization?

No, A4453 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for A4453?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A4453`, Rectal catheter with or without balloon, for use with any type transanal

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring a Written Order Prior to Delivery (WOPD), the signed SWO/WOPD must be received before delivery or the claim will be denied.
For DMEPOS base items that require a WOPD, the WOPD must list the base item and may list separately billed associated options, accessories, and supplies; separately billed associated items without a completed signed WOPD of the base item will be denied.

Claims must follow CMS HCPCS coding guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; claims not meeting coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) documentation is required to be maintained by the supplier and must be made available to the Medicare contractor upon request; services without appropriate POD shall be denied.

Suppliers must follow the LCD-related Standard Documentation Requirements Article, LCD-related Policy Article, and the DMEPOS Supplier Manual for additional documentation requirements and prior authorization rules.

General: documentation of prior conservative treatments attempted and their failure as described (diet, bowel habit changes, laxatives, medications) when coverage is predicated on failed conservative management.

Key Coverage Criteria

Bed pans (HCPCS E0275, E0276) are covered for beneficiaries who are bed-confined in accordance with NCD 280.1.
Items must meet Medicare coverage rules: be within a defined Medicare benefit category, be reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meet all other Medicare statutory and regulatory requirements.
Manual pump enema systems (e.g., Peristeen Anal Irrigation System, Coloplast, Minneapolis, MN) for the management of chronic neurogenic bowel when initial management involving diet, bowel habit, laxatives or constipating mediations has failed
Gravity-administered enema systems for the treatment of constipation, fecal incontinence, and bowel management protocols
Use of a stent for bowel obstruction due to colorectal malignancy for palliation and as a bridge to surgery.
HCPCS A4458 (Enema bag with tubing, reusable) — covered if selection criteria is met

3 Active Policies

ANTHEM-CG-MED-95, Transanal Irrigation

L36267, Bowel Management Devices

AETNA-CPB-0522, Bowel Management Devices

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A4453, Rectal catheter with or without balloon, for use with any type transanal